european network for psychosocial crisis management

Co-financed by the EU Commission

EUNAD No. ECHO/SUB/2012/640917

European Network for Psychosocial Crisis ManagementProf. Dr. Robert Bering

[email protected] of Psychotraumatology/ Alexianer

University of Cologne/ Faculty of Human Science

Kick off meeting 17.1.2013

Partners in the Project are

Germany, Center for Psychotraumatology, Alexianer, Krefeld Czech Republic, Charles University, Prague Denmark, University of Southern Denmark

Germany, Federal office of civil protection and disaster assistance, BonnNorway, Norwegian Center of Violence and Traumatic Stress Studies, Oslo


EUNAD No. ECHO/SUB/2012/640917 Objectives

• Initiatives of the European Commission for psychosocial aftercare in cases of disaster

• Target Group Intervention Program (TGIP)• Screening debate• Examples TGIP/ Cologne Risk Index (CRI)



Pre-traumatic Outline

Situational Components Coping Strategies, Effects

TraumaticSituation

TraumaticReaction

TraumaticProcess

Recovery

Time Course of Traumatic Stress

How can we improve the psychosocial aftercare for people affected by disasters? How can we prevent a traumatic process and support recovery?

ShockLife History



History of crisis intervention programs

1. First epoch of crisis interventionsT. W. Salmon (1919), A. Kardiner & H. Spiegel (1947)

2. Critical Incident Stress ManagementT. J. Mitchell & G. Everly (1997)

3. Critical turn in the debateS. Rose, J. Bisson & S. Wessely (2002). Cochrane Review on psychological debriefing for preventing PTSD.



Objectives of EUTOPA are:Implementation of EUTOPA products like

1. Multidisciplinary Guidelineon Early Intervention

2. Target Group Intervention Program


EUNAD No. ECHO/SUB/2012/640917 23 Countries were

represented in EUTOPADean Ajdukovic, David Alexander, Rosemarie Barwinski, Roman Birvon, Jonathan Bisson, Barbara Blanckmeister,David Bolton, Gernot Brauchle, Claudia Bredenbeck, Chris Brewin, Bruno Carlos Almeida de Brito, RanieriBrook Barbieri, Alarcos Cieza, Paul Cutajar, Francine Dal, Anita Deak, Katherine Deeley, Albert Deistler, FruzsinaDeme, Aida Maria dos Santos Dias, Michel Dückers, Jose Felix Duque, Ask Elklit, Lucy Faulkner, Maja Furlan,Eva Garossa, George Gawlinski, Eric Geerligs, Oliver Gengenbach, Stelios Georgiades, Berthold Gersons, Annika Gillispie, Irina Gudaviciene, Miroslav Harvan, TrondHeir, Leonie Hoijtink, Simona Hoskovcová, BarbaraJuen, Maria Kee, Zafiria Kollia, Uwe Korch, Dietmar Kratzer, Nora Lang, Talia Levanon, Vivienne Lukey, JanaMalikova, Robert Masten, Giulia Marino, José M.O. Mendes, Tiiu Meres, José Carlos Mingote Adán, MaureenMooney, Maria Eugenia Morante Benadero, Carlos Mur de Viu, Josée Netten, Àgatha Niemyjska, Ilina Nikolova,Brigit Nooij, Dag Nordanger, Lasse Nurmi, Miranda Olff, Francisco Orengo, Gerry O’Sullivan, AnthonyPemberton, Danila Pennacchi, Delphine Pennewaert, Pascal Perez Guertault, Cristiana Pizzi, Gerd Puhl, Raija-Leena Punamäki, Ralf Radix, Gavin Rees, Maire Riis, Magda Rooze, Claudia Roth, Arielle de Ruijter, Salli Saari,Rob Sardemann, Christina Schloßmacher, Claudia Schorr, Frederico Galvao da Silva, Jana Seblova, Aysen UfukSezgin, Erik de Soir, Marc Stein, Gisela Steiner, Sofia Stoimenova, Axel Strang, Jan Swinkels, Lajos Szabó,Dominique Szepielak, Petra Tabelling, Hans te Brake, Miguel André Telo de Arriaga, Graham Turpin, Willy vanHalem, Koen van Praet, Joszef Vegh, Ronald Voorthuis, Edgar Vor, Stepan Vymetal, Dieter Wagner, Lars Weisaeth, Martin Willems, Richard Williams, Moya Wood -Heath, William Yule, Bogdan Zawadzki



Manual I: Implementing the Cologne Risk Index-DisasterManual II: Measures for TGIPManual III: Trauma-based psychoinformationManual IV: Rehabilitation of stress response syndroms

Target Group Intervention Program (TGIP)

• TGIP offers a framework to plan psychosocial interventions from theacute phase up to the mid- and longterm course.

• TGIP is based on psychosocial and clinical experiences as well as empirical evidence, TGIP offers a tool of measures, depending on theriskprofile of the affected.

• TGIP contains the concrete description of actions for a gradual intervention planing that focusses first of all on the mid- and longtermtraumatic process.


EUNAD No. ECHO/SUB/2012/640917 Target Group Intervention program (TGIP)

Prognostical Screening: CRI-D

Group of RecoveryGuidance in Self-Help

Switcher

Monitoring

Clinical Diagnostic

In need of Trauma Therapy

Guidance in Self-Help

Trauma

High-Risk-Group

Trauma Therapy

Guidance in self-Help

PsychologicalFirst Aid

Information about professional help

Psychoinformation

Clinical Diagnostic

PsychologicalFirst Aid

Rehabilitation



What makes the difference betweenGuidelines and TGIP?

TGIP• Is a crisis intervention program of best practice• is based on a bio-psycho-social model• Is concipated on a time course model• Dynamics between risk and protective factors• Identifies target groups of risk (Cologne Risk Index)• Is adapted to different types of trauma incidents• Emphasizes mid- and longterm interventions• Integrates the ICF



Development and Modification of TGIP

• Collogne victim aid model (Fischer et al., 1997)• War Zone (Bering et al., 2003)• Bank Hold Up (Walter, 2003)• Train Accident Eschede/Brühl (Hammel, 2005)• PLOT - Terror Attack (Bering et al., 2005)• EUTOPA – IP Disaster (Schedlich et al., 2007)• Medical Care (Bering et al., 2007)• War Zone - Revalidated (Dunker, 2009)• School shooting (Weber, in preperation)



The screening debate

Constructed by Williams R & Kemp V after Layne CM, Warren JS, Watson PJ, Shalev AY. Risk,



Guidelines recommend:

• As yet the study group does not recommend the early tracing of those affected who have a high risk of a post-traumatic stress disorder using PTSD questionnaires (IMPACT, p 12)

• At present, it is the conclusion of this guidance that it is not appropriate to screen populations of people for symptoms in the immediate aftermath (days) of a disaster or traumatic event (NATO, p 87).

• No accurate way of screening for the later development of PTSD has been identified (NICE, p 107).

• Formal screening of everyone affected should not occur but helpers should be aware of the importance of identifying individuals with significant difficulties. (TENTS, p 5)

• All Guidelines agree that further studies are necessary.



Prognostical Screening in TGIP

• In TGIP we recommend a prognostical screening of risk factors (CRI), dissociation and PTSD related symptoms.

• Cologne Risk Index-Disaster enables the classification to Group of Recovery, Switchers and High-Risk Group and thereby establishes the basis of TGIP.

Qualitative studies/ Experts opinion Meta-Analysis

Field Studies



Conference Cologne 2011



Risk Factors for PTSDOzer et al., 2003

✓.35.14 – .94353416Peritraumatic Dissociation

✓.26.15 – .551.7555Peritraumatic Emotions

✓-.28.08 – .383.53711Perceived Social Support

✓.26.13 – .493.52412Perceived Life Threat

✓.17-.06 – .436679Family History of Psychopathology

✓.17-.13 – .476.79723Prior Adjustment

✓.17.00 – .465.30823Prior Trauma

StatisticallySignificant

EffectSeize

r

Range of effectseize

rN kRisikofaktor



Kölner Risiko Index - Fragebogen Datum: ............................... Code: 1. Ihr Alter in Jahren: 2. Geschlecht: männlich weiblich 3. Familienstand: alleinstehend verheiratet / feste

Partnerschaft geschieden / getrennt lebend

verwitwet

4. Anzahl der Kinder: 0 1 2 3 4 und mehr 5. Schulbildung: ohne Abschluß Hauptschule Realschule Abitur 6. Dienstgradgruppe: 7. Waffengattung: 8. Einsatzkontingent: 9. Einsatzdauer: 10. Anzahl bisheriger vergleichbarer Einsätze:

Für die Auswertung die Zeilensumme in der Summenspalte rechts außen eintragen: Σ

11. Waren Sie ausreichend auf den Einsatz vorbereitet? nein ja

12. Standen Sie vor dem Einsatz durch sonstige Lebensumstände unter Stress (z.B. familiär, finanziell bedingt etc.)?

nein ja

13. Wie stark fühlten Sie sich durch die Einschränkung der für Sie wichtigen sozialen Kontakte in der Heimat belastet ? extrem stark leicht keine

14. Gab es belastende Einsatzumstände, z.B. Klima, lange Arbeitszei-ten, Langeweile, schlechte Verpflegung, mangelhafte Unterbringung?

nein ja

15. Sind Ihre Erzählungen vom Einsatz und belastenden Erlebnissen in ihrem persönlichen Umfeld auf negative Reaktionen wie Desinteresse, Unverständnis oder Abwertung gestoßen?

nein ja

16. Dem Einsatz gegenüber bestehen Bedenken

wenn ja: bei Ihnen selbst in Ihrem direkten Lebensumfeld in der Öffentlichkeit

nein ja

17. Fühlten Sie sich von Kameraden unterstützt bzw. erlebten Sie einen guten Zusammenhalt der Gruppe?

nein ja

18. Fühlten Sie sich von Vorgesetzten unterstützt? nein ja

19. Als wie belastend bewerten Sie den Einsatz insgesamt? Belastung: extrem stark eher stark eher leicht leicht keine

20. Hatten Sie während des Einsatzes ein oder mehrere belastende / schwere Erlebnisse? ja, ein Erlebnis ja, mehrere Erlebnisse Wenn es ein oder mehrere belastende Erlebnisse gab, beantworten Sie bitte auch die folgenden

Fragen. nein

Wenn es kein belastendes Erlebnis gab, überspringen Sie die Fragen 21-27 und gehen Sie zum Validierungsteil über.

Cologne Risk Index: Questionnaire, half-standardizedinterview, guidance for taking history

Part A.

Sociodemographic aspects

Part B.

Antecedent factors:

Pretraumatization, stress ...

Post-situational factors:

Social support, appreciation, bodily injury, ability to speak wide open ...

Part C.

Peritraumatic factors:

Uncontrolled and unexpected, life-threatening/ fear of death, peritraumatic dissociation ...

Part D.

Semistandardized assessment of the dynamic in the situation



Intervalidation of the Cologne Risk Index in field studies

Bering et al., 2007, ZPPM



Application of TGIPA. Brake down of the Historical Archive

B. War zone related trauma


EUNAD No. ECHO/SUB/2012/640917 A. Collapse of the Historical Archive

of the City of Cologne„Cologne's archives are one of the only collections in Germany

to have survived World War II completely intact „

March 3rd, 2009



A: Lessons learned (acute phase)

• Multidisciplinary and trauma-centered staff is useful• The everyday needs of populations continue during and after

major incidents (Social workers!)• Screening of Target Groups at Risk/ Interview can wait

23



B. Development and Modification of TGIPWar Zone – Validated (2003/ 2009)

Reference: Bering, 2011; Dunker, 2009



Dunker 2009

Self-report: CRI- War Zone - Revalidated

Group of recovery Group of Switchers Risk Group

(Score 0-3) (Score 4-6) Score (7-18)



Sensitivity of CRI for Risk-Group T2 0.76 measured by PTSS-10

Sensitivity of 1.0 at T2 if cut of at 4.5 (Risk-Group and Switchers) measuredby PTSS-10

Prognostic sensivity/ specifityof CRI to predict symptoms

loads 6-8 month later (n=222)Group of recovery

Group of switchers

High-riskgroup



B: Lessons learned (midterm)

• The CRI allows a sufficient prognostical screening and distinguishes three different groups at risk.

Do not forget: The CRI is a check list that functions as a precurser for clinical diagnostics. The Screening and the Diagnostics are two different modules in the TGIP.

27



Love parade disaster, 2010Tsunami Japan, 2011

CBRN Incidents

Break down of the historicalarchive in Cologne, 2009



How to promote recovery after majorincidents?

Communication, Recovery and Resilience



Literature:

Downloads of TGIP: www.eutopa-info.euContact: [email protected]

Bering, R. (2011, 2. Auflage). Verlauf der Posttraumatischen Belastungsstörung. Grundlagenforschung, Prävention, Behandlung. Shaker Verlag: Aachen.Bering, R., Elklit, A., Schedlich C. & Zurek, G. (2009). Psychosocial Crisis Management: The role of Screening, Risk factors, and Psychopharmacology to prevent trauma related disorders. Zeitschrift für Psychotraumatologie und Psychologische Medizin, 3, 63-74. Bering, R., Schedlich, C. & Zurek, G. (2011). Großschadenslagen als potentiell traumatisierende Ereigniskonstellation. In: G. H. Seidler, H. J. Freyberger, A. Maerker (Hrsg.), Handbuch der Psychotraumatologie (S. 493-507). Stuttgart. Klett-Cotta.Bering, R., Schedlich, C. & Zurek, G. (2011). Situationstypologien der Psychosozialen Notfallversorgung. In: G. H. Seidler, H. J. Freyberger, A. Maerker (Hrsg.), Handbuch der Psychotraumatologie (S. 644-58). Stuttgart. Klett-Cotta. Bering, R. & Fischer, G. (2005). Kölner Risiko Index (KRI). In B. Strauß & J. Schuhmacher (Hrsg.), Klinische Interviews und Ratingskalen (S. 216–221). Göttingen: Hogrefe.

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european network for psychosocial crisis management

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